| Lake Geneva Wellness Clinic Llc | |
|
750 Veterans Pkwy Unit 100 Lake Geneva WI 53147-4950 | |
| (262) 248-7942 | |
| (262) 248-1202 |
| Full Name | Lake Geneva Wellness Clinic Llc |
|---|---|
| Speciality | Psychologist |
| Location | 750 Veterans Pkwy Unit 100, Lake Geneva, Wisconsin |
| Authorized Official Name and Position | Erika K Fountain (OWNER) |
| Authorized Official Contact | 2622487942 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Lake Geneva Wellness Clinic Llc 750 Veterans Pkwy Unit 100 Lake Geneva WI 53147-4950 Ph: (262) 248-7942 | Lake Geneva Wellness Clinic Llc 750 Veterans Pkwy Unit 100 Lake Geneva WI 53147-4950 Ph: (262) 248-7942 |
| NPI Number | 1003845181 |
|---|---|
| Provider Enumeration Date | 07/01/2006 |
| Last Update Date | 03/25/2021 |
| Certification Date | 03/25/2021 |
| Medicare PECOS PAC ID | 7517139447 |
|---|---|
| Medicare Enrollment ID | O20111018000668 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1003845181 | NPI | - | NPPES |
| 42126800 | Medicaid | WI |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | 811-057 (Wisconsin) | Primary |
| Provider Name | Duanne J Lafrenz |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1124057294 PECOS PAC ID: 8527156256 Enrollment ID: I20071114000252 |
| Provider Name | Laurie D Linden |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1659618346 PECOS PAC ID: 8325288590 Enrollment ID: I20130711000403 |
| Provider Name | Ashlie Moelter |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1619473998 PECOS PAC ID: 8123470275 Enrollment ID: I20240115000519 |
| Provider Name | Erika Karna Fountain-kiser |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1306023932 PECOS PAC ID: 9537332796 Enrollment ID: I20240116001166 |
| Provider Name | Sandra G. Betka |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1740531722 PECOS PAC ID: 4284086216 Enrollment ID: I20240116001290 |
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